Code No. 605.3E5
REQUEST TO PROHIBIT A STUDENT FROM ACCESSING SPECIFIC INSTRUCTIONAL AND LIBRARY MATERIALS
Request to prohibit a student from checking out certain instructional materials to be submitted to the superintendent. Please complete one form per student.
REQUEST INITIATED BY DATE ___________
Name ____________________________________________________________________________
Address __________________________________________________________________________
City/State _________________________ Zip Code__________________ Telephone_____________
Name of affected Student _____________________________________________________________
Requester’s Relationship to Student (must be parent/legal guardian)____________________________
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BOOK OR OTHER PRINTED MATERIAL TO PROHIBIT STUDENT FROM ACCESSING: |
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Author |
Hardcover |
Paperback |
Other |
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Title |
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Publisher (if known) |
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Date of Publication |
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MULTIMEDIA MATERIAL TO PROHIBIT STUDENT FROM ACCESSING: |
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Title |
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Producer (if known) |
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Type of material (filmstrip, motion picture, etc.) |
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Dated |
Signature |
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Approved: 08/15/2023
Reviewed:
Revised:
